AETNA LIFE INSURANCE COMPANY PO Box 1188, Brentwood, TN 37024 (800) 345-6022 OUTLINE OF MEDICARE SUPPLEMENT INSURANCE OUTLINE OF COVERAGE FOR POLICY FORM GR-11613-WI 01 MEDICARE SUPPLEMENT INSURANCE The Wisconsin Insurance Commissioner has set standards for Supplement Insurance. This policy meets these standards. It, along with, may not cover all your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see Wisconsin Guide to Health Insurance for People with, given to you when you applied for the policy. Do not buy the policy if you did not get this guide. PREMIUM INFORMATION We, Aetna Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in the same geographic area in this state. Your premium will change each year. The new premium will be based on your age. Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an Outline of Coverage describing your policy s most important features. This is not your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY If you find you are not satisfied with your policy, you may return it to Aetna Life Insurance Company, PO Box 1188, Brentwood, TN 37024. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments directly to you. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE The policy may not fully cover all of your medical costs. NEITHER AETNA LIFE INSURANCE COMPANY NOR ITS AGENTS ARE CONNECTED WITH MEDICARE. THIS OUTLINE OF COVERAGE DOES NOT GIVE ALL THE DETAILS OF MEDICARE COVERAGE. CONTACT YOUR LOCAL SOCIAL SECURITY OFFICE OR CONSULT MEDICARE AND YOU FOR MORE DETAILS.
AETNA LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT INSURANCE BASIC PLAN SUPPLEMENT (Part A) Hospital Expenses Per Benefit Period *A Benefit Period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Part A Benefits HOSPITALIZATION Semiprivate room and board general nursing and miscellaneous hospital services and supplies (Does not include personal items). Per Benefit Period First 60 days All but $1,260 each benefit period This Policy or [ ] Part A Deductible Rider** You Pay $1,260 or 61 st to 90 th Day All but $315 a day $315 a day 91 st day and after while using 60 lifetime reserve days All but $630 a day $630 a day Once lifetime reserve days are used: Additional 365 days 100% of Eligible Expenses* SKILLED NURSING FACILITY CARE You must meet s requirements, including having been in a hospital for at least 3 days and entered a -approved facility within 30 days after leaving the hospital Beyond the additional 365 days First 20 days 21st through 100th day 101st day and after All approved amounts All but $157.50 per day Up to $157.50 a day All costs All Costs *NOTICE: When your Part A hospital benefits are exhausted, the issuer stands in the place of and will pay whatever amount would have paid as provided in the policy s Core Benefits. **These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
BASIC PLAN (continued) SUPPLEMENT (Part A) Hospital Expenses Per Benefit Period Part A Benefits INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital BLOOD Per Benefit Period First 3 pints 190 days per lifetime This Policy 175 days per lifetime First 3 pints You Pay All charges not covered by policy nor by HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services Additional Amounts 100% All but very limited coinsurance or copayment for outpatient drugs and inpatient respite care
BASIC MEDICARE SUPPLEMENT POLICIES-PART B BENEFITS Once you have been billed $147 of approved amounts for covered services, your Part B deductible will have been met for the calendar year. Part B Benefits MEDICAL EXPENSES Eligible expense for physician s services, in-patient and outpatient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment Per Calendar Year First $147 of approved amounts Remainder of approved amounts Generally 80% or This Policy [ ] Optional Part B Deductible Rider** [ ]Optional Copayment Deductible Rider** Generally 20% You Pay $147 or or Up to $20 per office visit and up to $50 per emergency room visit. Charges in excess of 20% up to the limiting charge [ ] Optional Part B Excess Charges Rider** Balance, if any, or expenses if not covered by or this policy BLOOD First 3 pints All costs Next $147 of approved amounts or $147 Part B Deductible Charges not covered by the policy or Remainder of approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE 100% 100% of charges for visits considered medically necessary by 40 visits or [ ] Optional Additional Home Health Care Rider** Charges not covered by policy or **These are optional riders. You purchased this benefit if the box is checked and you paid the premium.
BASIC MEDICARE SUPPLEMENT POLICIES-PART B BENEFITS (continued) Part B Benefits PREVENTIVE MEDICAL CARE BENEFIT-NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Per Calendar Year First $120 each calendar year Additional charges $120 This Policy You Pay Charges not covered by policy or
THE FOLLOWING BENEFITS ARE MANDATED BY YOUR STATE: Skilled Nursing Facility Benefit - Non- Eligible Confinement-For confinement in a Wisconsin state licensed nursing facility we will pay the expense incurred for up to 30 days. Kidney Disease Benefit - We will pay inpatient and outpatient expense for dialysis, transplantation, or donor related services because of kidney disease. We won t pay for expenses paid for under, nor pay more than $30,000 in any one calendar year. If you have other coverage covering kidney disease expense, we won t pay more than our share. Chiropractic Benefit - When Part B does not pay for medically necessary services received from a chiropractor, we will provide payment in full for all usual and customary charges for chiropractor services. Benefits are not payable for any charges paid by. Diabetes Benefit - We will provide payment in full for all usual and customary expenses for: (a) the installation or purchase of an insulin infusion pump; (b) non-prescription insulin or any other non-prescription equipment or supplies for the treatment of diabetes, but not including any other outpatient prescription medications; and (c) diabetes selfmanagement education program. Benefits are not payable for any charges paid by. Hospital or Ambulatory Dental Benefit - We will provide payment in full for all usual and customary expenses incurred for hospital or ambulatory surgery center charges incurred and anesthetics provided in conjunction with dental care if any of the following applies; (a) the insured person has a chronic health condition; (2) the insured person has a medical condition that requires hospitalization or general anesthesia for dental care. Benefits are not payable for any charges paid by. Breast Reconstruction Benefit - We will provide payment in full for all usual and customary expenses incurred, in the manner recommended by the attending physician or oncologist to be appropriate for reconstruction of the affected tissue incident to a mastectomy. Benefits are not payable for any charges paid by. EXCEPTIONS, REDUCTIONS AND LIMITATIONS OF THE POLICY- We will not pay benefits for: (1) expenses deemed unnecessary or unreasonable by, except in the Benefit provisions and in Optional Riders, if any; (2) expenses incurred prior to the coverage effective date; (3) drugs (other than prescription drugs furnished during a hospital or skilled nursing facility stay; (4) custodial care, dental care (except as provided in the mandated benefits) eye or ear examinations to prescribe or fit eyeglasses or hearing aids, routine immunizations, cosmetic surgery or routine foot care; (5) services for which a charge is normally not make when there is no insurance; (6) nursing home care costs (beyond what is covered by and the Wisconsin 30-day skilled nursing mandated by Wisconsin 632.895(3); (7) home health care above the number of visits covered by and the 40-visits mandated by Wisconsin 632.895(2), unless you select the Additional Home Health Care Rider; (8) care received outside the USA Benefits will be increased to match any increases in deductible amounts or co-payment charges. The premium may automatically increase to correspond with these increases.
Renewability of the Policy -We will renew the policy each time you send us the premium. It must be paid on or before the date it is due or during the 31 days that follow. Your premium will change on the first renewal date that coincides with or follows the anniversary date of the policy. Material Misrepresentation - in the event of a material misrepresentation, the coverage will be cancelled as of the coverage effective date. A material misrepresentation occurs when a condition or combination of conditions you were requested to name on the application was not named and which, if named, would have caused us to deny issuing the coverage. This limitation for material misrepresentation is subject to the Time Limit for Certain defenses provision. Review and Appeal - In the event of the denial of a claim under the Policy, You may appeal such denial by submitting a written request, which may be in any form and which may include supporting material, for our review. We will provide a description of the review and notification to you regarding the results of the review within 30 days after receiving your request. Grievance - A grievance may be made by you or on your behalf in writing to us. A grievance is any dissatisfaction with the provision of services or claims practices by us. IN ADDITION TO THIS OUTLINE OF COVERAGE, AETNA LIFE INSURANCE WILL SEND AN ANNUAL NOTICE TO YOU, 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES, WHICH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.
MEDICARE SUPPLEMENT PREMIUM INFORMATION ANNUAL PREMIUM BASIC MEDICARE SUPPLEMENT COVERAGE OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT POLICY - Each of these riders may be purchased separately. PART A DEDUCTIBLE RIDER-100% of Part A Deductible PART B DEDUCTIBLE RIDER-100% of Part B Deductible PART B EXCESS CHARGES RIDER-Difference between what pays and the amount charged by the provider which shall be no greater than the actual charge or the limiting charge allowed by, whichever is less ADDITIONAL HOME HEALTH CARE RIDER-An aggregate of 365 visits per year including those covered by. FOREIGN TRAVEL RIDER-After a deductible of not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the United States.during the first 60 days of a trip with a maximum of at least $50,000. BASIC PLAN WITH MEDICARE COPAYMENT DEDUCTIBLE RIDER- the Part B coinsurance subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit that is in addition to the Part B medical deductible and in addition to out-of-pocket maximums. TOTAL FOR BASIC POLICY, POLICY FEE AND SELECTED OPTIONAL RIDERS Total Premium, if other than Annual Mode (at time of application), including premium for any Optional Rider selected above: $ EFT/Monthly $ Quarterly $ Semi-annual
AETNA LIFE INSURANCE COMPANY WISCONSIN-MONTHLY ATTAINED AGE RATES EFFECTIVE DATE: January 1, 2013 NON TOBACCO The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your payments automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain quarterly premium, multiply the monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6 or 12, respectively. If you elect to pay your premium on a monthly basis by check or money order, add $2 to the monthly premium shown to calculate your monthly premium amount. If you smoke and you enroll other than during the Supplement Open Enrollment and Guaranteed issue rights periods, a smoker premium rate will apply. Smoker premium rates are determined by multiplying the premium shown by a factor of 1.10.
The rates in the table below apply to the following ZIP CODES: 53500-53599, 53700-54999 Attained Age BASIC POLICY WITH BASIC POLICY PART B COPAY RIDER PART A DEDUCTIBLE RIDER MALE FEMALE MALE FEMALE MALE FEMALE 65 $106.00 $97.00 $82.58 $76.25 $13.67 $13.67 66 $110.91 $101.58 $86.00 $79.41 $15.17 $15.08 67 $115.83 $106.08 $89.33 $82.50 $16.58 $16.50 68 $120.75 $110.66 $92.75 $85.66 $18.08 $17.92 69 $125.66 $115.25 $96.16 $88.75 $19.58 $19.42 70 $130.49 $119.75 $99.41 $91.83 $21.08 $20.75 71 $135.41 $124.25 $102.83 $95.00 $22.50 $22.25 72 $140.24 $128.74 $106.16 $98.08 $24.00 $23.67 73 $144.91 $133.08 $109.33 $101.00 $26.42 $25.92 74 $149.58 $137.33 $112.50 $103.91 $28.75 $28.17 75 $153.83 $141.24 $115.41 $106.58 $31.08 $30.42 76 $158.33 $145.49 $118.50 $109.50 $33.50 $32.67 77 $162.91 $149.74 $121.58 $112.33 $35.83 $34.92 78 $165.24 $151.91 $123.16 $113.75 $39.17 $38.08 79 $167.58 $154.08 $124.66 $115.16 $42.50 $41.25 80 $169.08 $155.41 $125.58 $116.00 $45.75 $44.33 81 $171.33 $157.49 $127.08 $117.41 $49.16 $47.41 82 $173.66 $159.58 $128.58 $118.83 $52.50 $50.58 83 $173.83 $159.74 $128.16 $118.41 $62.75 $60.25 84 $174.08 $159.99 $127.74 $118.00 $73.08 $69.91 85 $174.74 $160.58 $128.58 $118.75 $80.58 $76.91 86 $175.33 $161.08 $129.33 $119.41 $88.41 $84.33 87 $175.74 $161.41 $129.99 $120.08 $96.66 $92.08 88 $176.08 $161.74 $130.74 $120.75 $105.25 $100.16 89 $176.33 $161.91 $131.41 $121.41 $114.25 $108.58 90+ $176.41 $161.99 $132.16 $122.00 $123.66 $117.41 Under 65 $451.40 $417.23 $321.32 $297.40 $69.25 $68.25 Home Health Care Rider $1.42 all ages, male and female Part B Deductible Rider $11.00all ages; male and female Part B Excess Rider $3.50 all ages; male and female Foreign Travel Rider $1.42 all ages; male and female
The rates in the table below apply to the following ZIP CODES: 53000-53299, 53400-53499 Attained Age BASIC POLICY MALE FEMALE BASIC POLICY WITH PART B COPAY RIDER MALE FEMALE PART A DEDUCTIBLE RIDER MALE F EMALE 65 $121.90 $111.55 $94.97 $87.68 $15.72 $15.72 66 $127.55 $116.82 $98.90 $91.33 $17.44 $17.35 67 $133.20 $121.99 $102.73 $94.87 $19.07 $18.97 68 $138.86 $127.26 $106.66 $98.51 $20.80 $20.60 69 $144.51 $132.53 $110.59 $102.06 $22.52 $22.33 70 $150.07 $137.71 $114.32 $105.60 $24.24 $23.86 71 $155.72 $142.88 $118.25 $109.25 $25.87 $25.59 72 $161.28 $148.06 $122.09 $112.79 $27.60 $27.22 73 $166.65 $153.04 $125.73 $116.15 $30.38 $29.80 74 $172.01 $157.93 $129.37 $119.50 $33.06 $32.39 75 $176.90 $162.43 $132.72 $122.57 $35.74 $34.98 76 $182.08 $167.32 $136.27 $125.92 $38.52 $37.57 77 $187.35 $172.21 $139.82 $129.18 $41.21 $40.15 78 $190.03 $174.70 $141.64 $130.81 $45.04 $43.79 79 $192.71 $177.19 $143.36 $132.44 $48.87 $47.44 80 $194.44 $178.72 $144.42 $133.39 $52.61 $50.98 81 $197.03 $181.12 $146.14 $135.02 $56.54 $54.53 82 $199.71 $183.51 $147.86 $136.65 $60.37 $58.17 83 $199.90 $183.71 $147.39 $136.17 $72.16 $69.28 84 $200.19 $183.99 $146.91 $135.69 $84.04 $80.40 85 $200.95 $184.66 $147.86 $136.56 $92.67 $88.45 86 $201.63 $185.24 $148.73 $137.32 $101.68 $96.98 87 $202.10 $185.62 $149.49 $138.09 $111.16 $105.89 88 $202.49 $186.01 $150.36 $138.86 $121.03 $115.19 89 $202.78 $186.20 $151.12 $139.62 $131.38 $124.87 90+ $202.87 $186.29 $151.99 $140.29 $142.21 $135.02 Under 65 $519.11 $479.82 $369.52 $342.02 $79.63 $78.48 Home Health Care Rider $1.63 all ages, male and female Part B Deductible Rider $12.65 all ages; male and female Part B Excess Rider $4.02 all ages; male and female Foreign Travel Rider $1.63 all ages; male and female